Citation: Sundermeir, S.M.; Winkler,

M.R.; John, S.; Colón-Ramos, U.;

Kaur, R.; Hickson, A.; Dombrowski,

R.D.; Hill, A.B.; Bode, B.; DeAngelo,

J.; et al. A Commentary on the

Healthy Community Stores Case

Study Project: Implications for

Retailers, Policy, and Future Research.

Int. J. Environ. Res. Public Health 2022,

19, 8824. https://doi.org/10.3390/

ijerph19148824

Academic Editor: Paul B. Tchounwou

Received: 21 June 2022

Accepted: 19 July 2022

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International Journal of

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Commentary

A Commentary on the Healthy Community Stores Case StudyProject: Implications for Retailers, Policy, and Future ResearchSamantha M. Sundermeir 1,* , Megan R. Winkler 2, Sara John 3, Uriyoán Colón-Ramos 4 , Ravneet Kaur 5,Ashley Hickson 3, Rachael D. Dombrowski 6, Alex B. Hill 7, Bree Bode 6 , Julia DeAngelo 8 and Joel Gittelsohn 1

1 Department of International Health, Bloomberg School of Public Health, Johns Hopkins University,Baltimore, MD 21205, USA; jgittel1@jhu.edu

2 Department of Behavioral, Social and Health Education Sciences, Rollins School of Public Health,Emory University, Atlanta, GA 30322, USA; megan.winkler@emory.edu

3 Center for Science in the Public Interest, Washington, DC 20005, USA; sjohn@cspinet.org (S.J.);ahickson@cspinet.org (A.H.)

4 Milken Institute School of Public Health, George Washington University, 950 New Hampshire Avenue,Washington, DC 20052, USA; uriyoan@gwu.edu

5 Department of Family and Community Medicine, University of Illinois College of Medicine,Rockford, IL 61107, USA; ravneetk@uic.edu

6 Division of Kinesiology, Health and Sport Studies, College of Education, Wayne State University,Detroit, MI 48202, USA; rjankows@gmail.com (R.D.D.); bodebr@wayne.edu (B.B.)

7 Urban Studies and Planning and Detroit Food Map Initiative, Wayne State University, Detroit, MI 48202, USA;alexbhill@wayne.edu

8 Departments of Health Policy Management & Nutrition, Harvard T.H. Chan School of Public Health,Harvard University, Boston, MA 02115, USA; jdeangelo@hsph.harvard.edu

* Correspondence: srex2@jh.edu

Abstract: In the United States, low-income, underserved rural and urban settings experience pooraccess to healthy, affordable food. Introducing new food outlets in these locations has shown mixedresults for improving healthy food consumption. The Healthy Community Stores Case Study Project(HCSCSP) explored an alternative strategy: supporting mission-driven, locally owned, healthycommunity food stores to improve healthy food access. The HCSCSP used a multiple case studyapproach, and conducted a cross-case analysis of seven urban healthy food stores across the UnitedStates. The main purpose of this commentary paper is to summarize the main practice strategiesfor stores as well as future directions for researchers and policy-makers based on results from theprior cross-case analyses. We organize these strategies using key concepts from the Retail FoodEnvironment and Customer Interaction Model. Several key strategies for store success are presentedincluding the use of non-traditional business models, focus on specific retail actors such as storechampions and multiple vendor relationships, and a stores’ role in the broader community context, aswell as the striking challenges faced across store locations. Further exploration of these store strategiesand how they are implemented is needed, and may inform policies that can support these types ofhealthy retail sites and sustain their efforts in improving healthy food access in their communities.

Keywords: healthy food retail; food access; low-income; community food store; locally owned; casestudies; qualitative

1. Introduction

In the United States, low-income, underserved rural and urban areas are challenged bypoor access to healthy, affordable food [1,2]. These areas tend to have low access to super-markets and discount warehouse stores, whereas smaller food retailers (e.g., corner stores,convenience stores) are typically more common, providing easy access to food options, butoffering an array of unhealthy options and high prices [2,3]. Policies and initiatives, suchas the Healthy Food Financing Initiative (HFFI) [4], have supported healthy food retail

Int. J. Environ. Res. Public Health 2022, 19, 8824. https://doi.org/10.3390/ijerph19148824 https://www.mdpi.com/journal/ijerph

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projects over the last decade. The HFFI aims to improve healthy food access; for example,the introduction of supermarkets in low-income, low-access locations. However, suchprojects have shown mixed results in terms of improving food purchasing and consump-tion patterns [5]. These mixed results are due to many reasons, including low adoptionof these new supermarkets as a regular shopping venue, and a lack of understanding ofstore- and community-level factors, such as pricing structures, marketing practices, andcommunity buy-in that influence diet-related behaviors aside from access alone [5].

An alternative approach to understanding how to improve dietary quality is exam-ining existing mission-driven, locally owned food stores who are already committed toimproving healthy food access in their community. Such work would add to previousresearch examining grocery store accessibility and in-store interventions (e.g., pricing, place-ment) [6–13], by understanding which successful strategies and approaches may be scalableto other venues. It could also provide insight into the policy supports necessary to ensurethat other food retailers are able to shift their missions to prioritize health and accessibilityand identify key gaps in knowledge that should be addressed in future research.

The Healthy Community Stores Case Study Project (HCSCSP) was the first of its kindto explore this strategy, by delving into the structure and operations of seven mission-driven, locally owned food stores in low-income urban locations [14] using a multiple casestudy approach [15]. Additional details about the selection process of the seven stores, theirdistinct characteristics and contexts, and the study protocol have been previously publishedas part of this special issue [14]. Briefly, the seven stores were located in cities across theUS mid-west and northeast who served low-to-middle income neighborhoods who werealso predominantly immigrant or African American communities [14] The results of thecross-case analyses, including specific community engagement approaches and strategiesused by stores to meet their healthy food accessibility missions, as well as barriers andfacilitators, have already been described in other studies within this special issue [16–19].The focus of this commentary is to draw on the insights from across the HCSCSP studiesaugmented with relevant literature from multiple fields (e.g., nutrition, food retail, business,and economics) to provide future practice, research, and policy implications that couldpromote the expansion of mission-driven work around healthy food accessibility acrosslow-income communities.

We have organized our presentation of key insights using the Retail Food Environmentand Customer Interaction Model [20], as others have previously done [21]. This modelcaptures the retail food environment and customer relationships that lead to a range ofsocietal challenges and helps to organize the complex and dynamic food environment intoseveral, clearly defined components [20]. Below, we organize the insights drawn fromacross the HCSCSP studies by three key areas outlined in the model: business models;retail actors, and the larger macro-level contexts, including the socio-political landscape inwhich retailers and communities are embedded. Within each area, we describe evidencefrom the HCSCSP cases and literature, and then provide specific implications for stores,researchers, and policy-makers to consider.

2. Business Models

The business model component of the Retail Food Environment and Customer In-teraction Model refers to the different business designs as well as ownership/financialmodels utilized which reflect the overall priorities and goals of a business [20]. Across thecases, we found four features of business models to be key, including: (1) store commitmentto and investment in their community, (2) the type of ownership/financial model used,(3) the importance of hiring local staff, and (4) the implementation of needs-based andloyalty programs.

2.1. Commit to Community Engagement

Overall, a store’s commitment to community engagement was one of the most im-portant factors in a business model [17,18]. This was even more important when socio-

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cultural differences were present among the store owners/managers and the communityresidents [19]. We found that each store approached their mission in different ways—inparticular, how they engaged and interacted with their surrounding community [18]. Allstores were operating in environments with complex and varied historical contexts, cus-tomer populations and demands, and financial considerations. That said, stores that took abroader role as a store serving their community demonstrated different priorities whichhelped shape strategies for improving healthy food access in their specific context. Thefollowing are specific practice implications for stores and future directions for researchersand policy-makers to consider as it relates to exploring ways to incorporate communityengagement into a store’s business model.

Store-Level Practice Implications:

• Learn about the historical contexts and resident dynamics in the community beingserved from the outset, and continue to learn over time. This can be achieved throughpartnering with community organizers and conducting formal or informal formativeresearch that includes qualitative (interviews, focus groups) and quantitative data(community and/or customer surveys). Academic institutions could be key partnersin conducting this type of research.

• Ensure frequent, bidirectional communication to and from the community. Thismay be accomplished through social media posting, hosting or attending communityevents, and customer suggestion boxes.

• Be clear about the store mission and its ability to achieve that mission to establishcommunity trust. This may include producing annual reports or updates that arepublicly available.

• Collaborate with key community stakeholders to invest in healthy food promotionactivities (e.g., taste tests with a local school or healthy cooking classes with communitymembers in store).

Future Research Directions:

• Explore how community engagement approaches vary across urban, suburban, andrural settings.

• Continue to explore the motivations among retailers that prioritize community en-gagement, and to inform scalability and sustainability.

• Explore how a community advisory board could be created and collaborated with toguide store-level policies and practices, as well as local-level policies.

Policy Implications:

• Consider incentivizing or financing stores that invest in community prosperity andhealth as part of their business model (e.g., through providing certificate or trainingprograms tied to small financial incentives). Develop criteria for identifying storeswho qualify to receive these types of incentives (related to store size, location, localownership, mention of prioritizing healthy foods in the store mission, etc.).

2.2. Use New Ownership/Financial Models

Ownership/financial models in this project were diverse and included for-profit, non-profit, and cooperative models. As simply introducing new food outlets in areas with lowfood access has not been as successful as hoped, shifting gears from traditional businessmodels, such as for-profit, to alternative business models such as non-profits or co-ops mayensure a sense of shared ownership in the community [18].

Non-traditional business models may also allow for more flexibility to stick to a healthyfood-focused mission and offer healthy foods at an affordable price [17]. For example,some stores were able to create nutrition guidelines for provisioning healthy food, andreceived funding from non-traditional funding sources, such as foundations, fundraising,city grants, and individual donors. Non-profit stores in this project scored higher on thepricing component of the Healthy Food Availability for Healthy Eating Index, meaningthat they were able to offer lower prices compared to other business model types [16].

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The retail literature suggests that innovative business models also allow for flexibilityand adaptability in response to the surrounding built and social environment throughnon-traditional practices [22,23]. Innovations to one or more of the main componentsof a business model (i.e., value proposition, value delivering, value creation, and valuecapturing) can determine the values a business creates, who receives the benefit of thevalues created, and how the business relates to consumers [22]. For example, a place-basedbusiness model makes use of location-specific resources (i.e., local producers, distributors)to create value [22]. This can ultimately lead to increased resilience and sustainability ofthe retailer, stronger customer relations, as well as the success of the local economy [22,23].Moreover, non-economic goals of the retailer may reflect values shared by both the retailerand the consumer, and could thus be achieved through non-traditional business modelssuch as co-ops, where the consumers are owners with multiple mechanisms to influencestore decision-making [24].

Store-Level Practice Implications:

• Consider a non-traditional business model that allows for shared ownership, leader-ship, and decision-making within the community. Allow for community input fromthe store’s inception including the selection of the location to developing the store’shealthy food mission and what healthy foods are sold in the store.

• Establish partnerships with local producers, gleaners, or other food donors to createother food sourcing options outside of traditional wholesalers and suppliers.

• Create nutrition guidelines for what can be provisioned and sold in the store. Involvethe community in deciding what nutritional factors are most important to them interms of what foods/nutrients to limit, and what foods/nutrients to encourage.

Future Research Directions:

• Develop insights into what type of business models current and future store ownerswould be willing to explore. Identify the barriers/facilitators to following each modelto elucidate the best way to build capacity amongst local store owners to adopt non-traditional business models.

• Similarly, identify how policy-makers view different business models. Understandingwhat type of business models policy-makers would be more willing to support mayinform future policies to financially support and incentivize new and existing stores.

Policy Implications:

• Streamline the process for becoming a non-profit grocery store, as well as the subse-quent reporting, to be more feasible for store owners.

• Increase funding for technical assistance and capacity building among non-profitgrocery store models to promote and protect sustainability, especially in places wherefood sovereignty is a public health goal.

2.3. Hire Local Staff

Business models also must consider who they hire and how this can add or detractfrom their mission. With retailers committed to the well-being of their communities, hiringstaff from the community and empowering them to participate in decision-making can beessential for a business to thrive. Previous work has shown that businesses who hire localstaff tend to experience a variety of benefits including lower recruitment costs, reducedturnover, and enhanced brand reputation [25]. Hiring locally also promotes inclusiveness,improves the local economy and helps build community capacity, bolstering the idea of theimportance that stores recognize their broader role in the community [18,26,27].

Store-Level Practice Implications:

• Aim to hire staff from the surrounding neighborhood and community. This may beachieved through local advertisements, word-of-mouth, attending community eventsto network, and social media postings.

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• Establish partnerships with community organizations and existing programs to de-velop and/or participate in workforce training programs [26].

Future Research Directions:

• Explore key strategies that stores undertake to successfully hire and maintain localstaff and document what is needed to inform strategies for other stores who wouldlike to incorporate this practice into their business model.

• Examine how incorporating such a practice influences aspects of store success and sus-tainability, including community engagement, customer satisfaction, and foot traffic.

Policy Implications:

• Incentivize stores who hire local staff in low-income settings.• Engage stores in local, state, and federal-level programs that provide workforce train-

ing opportunities for youth and young adults (e.g., AmeriCorps).

2.4. Implement Needs-Based or Loyalty Programs

Some stores in the project also employed a needs-based program or loyalty programsas part of their business approach. While the loyalty program incentivized repeat cus-tomers, the needs-based program made healthy food more accessible to groups with limitedresources [17]. Specifically, the needs-based program helps to level the playing field byhaving those who identify as ‘needs-based’ pay a lower price at the check-out every time.The use of innovative, non-traditional strategies, such as the needs-based program aswell as the ability to accept donations and collaborate with innovative suppliers, can helpequitably address both the affordability aspect for consumers as well as offset the costs forretailers to ensure financial viability.

Store-Level Practice Implications:

• Offer a loyalty program or needs-based program for repeat and/or lower-incomecustomers to increase the affordability of the healthy foods being sold, and buildcustomer loyalty. A needs-based program provides a discount at every check-out forthose who qualify based on self-reported need or income (in this project, customersreceived a 10% discount).

• Offer discounts and promotions to be competitive with surrounding stores.• Conduct competitive price analyses regularly.

Future Research Directions:

• Further examination of different customer programs/incentives, how they operate andwhat their impact is on food access and healthy food purchase is needed, especiallyacross business model type.

• Test the impact of implementing loyalty and needs-based programs on customersatisfaction, foot traffic, and purchasing patterns of healthy foods.

Policy Implications:

• Incentivize pricing structures that further enable access to low-income shoppers, suchas a needs-based program.

3. Retail Actors

Retail food actors are the people that work within the retail food environment atdifferent levels across the food supply chain, such as managers, distributors, and salesrepresentatives [20]. In this multiple case study project, we found two key actors to beessential to mission-driven, locally owned food stores: store champions and vendors.

3.1. Identify and Work with Store Champions

Store champions were present in all seven stores, and were typically a higher-levelstaff member with great passion and commitment to the store as well as to its healthyfood mission [17]. The importance of a store champion, or local community business own-ers/staff, on influencing community health values and being agents of health promotion

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has been demonstrated in the context of supermarkets. For instance, Tesco in the UnitedKingdom has over 300 fully funded community champions that act as the link between thestore and the community [28], as well as other business settings [17,29–33].

Store-Level Practice Implications:

• If the store does not have a local store champion (i.e., it is not locally owned), con-sider hiring a manager from the surrounding community who is passionate aboutimproving food access and health in the community [28]. This person should beinvolved in store decision-making and trained on other aspects of store managementand operations; however, the general passion and commitment to this work cannotnecessarily be learned.

Future Research Directions:

• More research is needed to explore the role of a store champion, identifying strategiesfor engaging active community members who could become a store champion instores that do not already have one as well as understanding the impact that gaining astore champion can have on store success.

3.2. Diversify Vendors

Another set of retail actors identified as key to store success in this project were productvendors. Many of the stores who utilized multiple vendors versus one or a few were ableto offer lower prices to their customers [17]. Product vendors are key to business success,and not having adequate vendor relations has been identified as a barrier to entry into themarket for new stores, given vendors may already have strong relationships with existingstores and/or larger chains [34,35].

The retail literature also suggests that the supply chain for unhealthy foods (i.e., saltyand sweet snacks, sugar-sweetened beverages) in small store settings is more robust thanthat of healthier options (i.e., fresh produce); unhealthier products can often be deliveredto the store (whereas it is often not possible, or more expensive to have healthier itemsdelivered), and vendors may offer incentives for purchasing these products [36–38]. Largerproduct vendors often have minimum order requirements which can be challenging tomanage for small stores, especially for healthy perishable items that can spoil and detractfrom the business bottom line [36,37,39]. Stores can work together in collaboration withvendors to obtain multiple vendor options (traditional and non-traditional, such as localproducers, gleaners, donors) and improve the supply chain of healthy foods to smallerstores, which could be supported by policies that incentivize these relationships. Perhapsfocusing on local store–vendor relationships would lend itself to collaboration and beof interest to local policy-makers interested in improving healthy food access in theircommunities [39], as well as at the federal level where input is currently being solicited forbetter supporting small, mid-sized, and independent processors [40]. In addition, havingmultiple avenues for sourcing food may increase a store’s resiliency during supply chaininterruptions such as those experienced during the COVID-19 pandemic [41].

Store-Level Practice Implications:

• Engage multiple vendors by dedicating staff time to explore local, regional, andnational purchasing opportunities.

• Consider working with local vendors to further increase community relations andsupport the local economy.

• Consider working with other local small retailers to coordinate collective purchasingthat creates economies of scale.

Future Research Directions:

• Further explore how existing stores identify and maintain relationships with multiplevendors to understand the process and provide guidance for stores who would liketo increase the number of vendors they utilize. Of interest may be assessment ofstores who already practice collective purchasing with partner stores, and testing

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this strategy more broadly. Development of digital strategies and platforms withuser-friendly features that facilitate these relationships may be beneficial.

Policy Implications:

• Consider providing tax incentives to vendors who distribute healthier food items insmaller batches to small stores, or who are working to build capacity to do so.

• Incentivize local food distribution hubs that can support community store fresh pro-duce orders.

• Support initiatives that aim to localize the food supply chain and thus facilitate theestablishment of new local vendor–retailor relationships.

4. State, Tribal, National, and Global Context

The state, tribal, national, and global context of the Retail Food Environment and Cus-tomer Interaction Model refers to macro-level factors and contexts, such as policies, that caninfluence all aspects of the retail food environment, including the surrounding community,retail actors, and relationships [20]. In this section, we reflect on the various contexts thatimpacted stores in our study and the policy solutions that could be implemented to helpaddress and mitigate these larger contextual forces. Specifically, we discuss the impactsfrom the COVID-19 pandemic and unintentional constraints placed on small stores fromfederal food policies.

Unmitigated structural racism has resulted in unequal access to healthy affordablefood (among other critical resources) particularly in Black and Latinx communities [42]. Oneway to begin to take action to address these inequities in food access and the consequentialnegative health outcomes is to support smaller, locally owned, mission-driven food retailerslike the ones included in this case study project, as opposed to larger chains. One storereceived city funding to support the store in stocking and selling of healthier options,highlighting the importance of supporting the “supply-side” of food retail, not just thedemand side, which is often the focus of federal-level policies related to food assistanceprograms. Strategies such as federal-level funding or state and local tax breaks for storeswho prioritize making healthy foods affordable may incentivize new and existing stores tofocus on health.

4.1. Impacts of the COVID-19 Pandemic

Many food retail stores suffered during the COVID-19 pandemic due to overall de-creased foot traffic [34], supply chain shortages [43], increased prices [43,44], and theinability, particularly for small stores, to offer online shopping or delivery options [45,46].Small stores such as the ones included in this case study were forced to look for otherfunding opportunities, and in one case, the store closed its doors, while the PaycheckProtection Program mostly supported larger companies. Although the business strategiesoutlined above (i.e., use of multiple vendors, flexibility in where food and funding can comefrom) cannot completely protect a business from the impact of an event like the COVID-19pandemic, it may help increase resiliency during these times of hardship by having manysupporting partners and avenues for continuing to serve food in their communities [41].

Future Directions for Research:

• Explore variation in COVID-19 adaptations by urban, suburban, and rural settings.• Based on lessons learned from store adaptations during the COVID-19 pandemic,

develop strategies and protocols for store emergency preparedness in collaborationwith store staff.

Policy Implications:

• Prioritize smaller stores with fewer staff and resources in emergency relief acts infuture national or global crises.

• Provide ample opportunities for technical assistance and other supports targetedto smaller, locally owned, mission-driven stores who have less capacity to navigatebureaucratic forms and applications.

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4.2. Federal Food Policy Constraints

At the federal level, small, locally owned food stores should be considered in futurepolicies related to the Supplemental Nutrition Assistance Program (SNAP) and the SpecialSupplemental Nutrition Program for Women, Infants, and Children (WIC). Expansionof guidelines to allow smaller retailers to feasibly offer and maintain acceptance of foodassistance benefits may improve food security in the communities they serve. For example,expanding the WIC eligible food product list to include alternative healthy food options,outside of conventional products, may encourage smaller stores to participate. In onestore, a large barrier to WIC participation was the constraints of the food product list. Thestore had to collaborate with other retailers in their city to be able to order the specificconventional products required by WIC and offer them in the store, as their preferred,environmentally sustainable products did not qualify. Ultimately, consideration for thesesmaller stores with fewer resources but significant mission-driven work is needed in futurepolicy formation as they are vital to serving the community.

Future Directions for Research:

• Simulate or test the feasibility of the potential policies and strategies described above,using tools such as casual loop diagrams and system dynamics modeling, to assesstheir potential impacts, as has been done in other studies [12,47–50].

• Explore the acceptability and perceived feasibility of such policies and strategiesamong store owners and policy-makers, and understand their views on how theseprocesses could be streamlined and made more accessible.

Policy Implications:

• Expand federal nutrition program guidelines to make participating as a WIC and/orSNAP vendor more accessible to smaller, locally owned, mission-driven stores withfewer resources.

• Provide technical assistance centers for SNAP-authorized retailers that could providebest practices, resources on sourcing, and stocking healthy foods.

• Expand the Gus Schumacher Nutrition Incentive Program (GusNIP) to communitystores to financially incentivize fruit and vegetable purchases made with SNAP benefitsat these stores.

• Collaborate with Healthy Food Incentive Programs at the state level, such as withWomen, Infants, Children (WIC) and/or Supplemental Nutrition Assistance Programs(SNAP) so that loyalty programs and discounts/coupons are connected to consumeraccounts with WIC and/or SNAP.

5. Conclusions

The Healthy Community Stores Case Study Project was novel in its attempt to deeplyexplore how mission-driven, locally owned food stores who prioritize healthy food navigatetheir complex local food systems in order to survive and thrive. This project brought tolight several key strategies for store success as described here, as well as apparent trials andtribulations faced across store locations during standard operations along with the eventsof 2020 with the COVID-19 pandemic. Further exploration of these store strategies and howthey are operationalized across urban, suburban, and rural locations is needed in order totest them in other stores, as well as to inform policies that support these types of healthyretail sites and sustain their efforts in low-income, low-healthy food access communities.

Author Contributions: Conceptualization, S.M.S., M.R.W. and J.G.; methodology, S.M.S., M.R.W. andJ.G.; writing—original draft preparation, S.M.S.; writing—review and editing, M.R.W., S.J., U.C.-R.,R.K., A.H., R.D.D., A.B.H., J.D., B.B. and J.G. All authors have read and agreed to the publishedversion of the manuscript.

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Funding: This work was supported by Healthy Eating Research, a national program of the RobertWood Johnson Foundation. Further support was provided to S. M. Sundermeir by the NationalInstitute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health T32Predoctoral Clinical Training Grant, and to M. R. Winkler by the National Heart, Lung, and BloodInstitute under award R00HL144824 (PI: M. Winkler). The content is solely the responsibility of theauthors and does not necessarily represent the official views of the National Institutes of Health or theRobert Wood Johnson Foundation. Funding agencies had no role in the design, analysis or writing ofthis article. Data collection in DC was also made possible by support from the Institute for Interna-tional Economic Policy, Elliott School of International Affairs at the George Washington University.

Institutional Review Board Statement: Not applicable.

Informed Consent Statement: Not applicable.

Data Availability Statement: Not applicable.

Acknowledgments: We would like to thank the store staff across the seven sites in this case studyproject for their time and insightful contributions that made this work possible.

Conflicts of Interest: The authors declare no conflict of interest.

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